Healthcare Provider Details

I. General information

NPI: 1447539507
Provider Name (Legal Business Name): KRISTIN L MACK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTIN MICHELLE LAKE

II. Dates (important events)

Enumeration Date: 08/08/2011
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 FINNEY BLVD
MALONE NY
12953-1067
US

IV. Provider business mailing address

125 FINNEY BLVD
MALONE NY
12953-1067
US

V. Phone/Fax

Practice location:
  • Phone: 518-481-8160
  • Fax: 518-481-8161
Mailing address:
  • Phone: 518-481-8160
  • Fax: 518-481-8161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number272786
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: